1. Beom Koo Lee, M.D. Dept. of Orthopaedic Surgery Gil Medical Center, Gachon University Operation of Arthritic Knee - HTO vs UKA -

2. Arthroscopic Debridedment Cartilage Transplantation Osteotomy UKA TKA Surgical Options for Mono-compartmental OA

3. Discussion Point to compare HTO vs UKA Trend Survival Function Kinematics Indication & contraindication Biologic aspect Perioperative morbidity  Weight bearing, Rehabilitation, General Complication Problem  Complication  Cosmetics  Technical Problem associated with TKA after Procedure

4. Trend

5. The early reported series of unicompartmental knee replacement done by experienced surgeons did not have encouraging results, with 70% survivorship reported at 5 to 7 years, and 65% and 53% survivorships reported at 11 and 12 years, respectively. Callahan, CORR, 2005 Trend of UKA

6. However, more recently the reports of unicompartmental knee replacement have been more encouraging with 94% survivorship at 10 years and 90% survivorship at 18 years. Callahan, CORR, 2005 Trend of UKA, Recently

7. The UKA preserve Normal Kinematics Patil, JBJS(Am), 2005 Kinematics of UKA

8. Patil, JBJS(Am), 2005 Kinematics of UKA

9. Patil, JBJS(Am), 2005 Kinematics of UKA

10. Kinematic of UKA Variable Femoral Roll Back Dennis, JBJS(Am), 2001

11. Indications & Contraindications

12. Young Active Male Varus Deformity Mont, AAOS ICL, 2004 Ideal Indications of HTO

13. Low Demand Female Elderly No instability & Contracture Correctable Deformity Mont, AAOS ICL, 2004 Ideal Indications of UKA

14. Contraindications HTOUKA Severe Deformity+(?)+ ACL Insufficiency- + P-F Arthritis++ Obesity++ Inflammatory Arthritis++ Advanced Age + - Arthritis Opposite++ Severe Contracture++ Medial Plateau Depression + - Lateral Instability++

15. UKA  Varus 10 - 20°  Valgus < 15°  Preferably 10° Pagnano, AAOS ICL, 2005 osteotomy  Even Severe Deformity over 20 can be corrected by Dual Osteotomy.  Hanssen Insall 3 rd edit Range of Correction

16. T-F angle : Varus 14° Mechanical Axis : Varus 20°

17. moderate to severe Lateral instability, and subluxation is contraindicated in HTO (Insall 3 rd edit) TKA is advisable in Great subluxation than UKA ( Insall 3 rd edit) UKA is contraindicated for instability (ICL 2005) Management in Mild Lateral Laxity in HTO  Slight Overcorrection  Reefing of LCL 배대경  Spontaneous shortening 조세현 Lateral Instability

18. ACL Instability in UKA ACL insufficiency ; relative contraindication in UKA ICL 2005 HTO can be done in ACL Deficiency Noyes, Am J Sports Med, 2000

19. UKA in Elderly O’Rourke, CORR, 2005

20. UKA 는 HTO 에비해 비교적 Deformity 정 도가 적어야하고, Ligament 가 Stable 해 야한다. UKA 에서 80 세 이상의 노인이나, 40 대의 여성에서 유리하다. HTO 는 활동이 많은 젊은 나이에 유리하다. Summary of Indications

21. Survival

22. Survival of UKA O’Rourke, CORR, 2005

23. Survival of UKA Stukenborg, The Knee, 2001

24. Despite an accelerated recovery and decreased hospital stay in our MIS- UKA, the rate of Revision due to aseptic loosening and the overall Reoperation rate compare to unfavorably with those performed with an open technique. Engh, J Arthroplasty, 2006 Survival of MIS-UKA

25. Survival of HTO Insall & Scott, Surger of the Knee, 4 th ed.

26. Survival of HTO & UKA 배대경, 대한슬관절학회지, 2001 배대경, 대한정형외과학회지, 2002 UKA HTO

27. 과교정된 HTO 나 UKA 는 결과가 비슷하다. 젊은 나이에서는 UKA 는 비교적 초기에 실 패한다. Summary of Survival

28. Quality of Life

29. Results of HTO vs UKA Broughton, JBJS(Br), 1986 UKA Results were signinficantly Better than HTO

30. Function of HTO vs UKA Stukenborg, The Knee, 2001 Better Function in HTO

31. Pain of HTO vs UKA Broughton, JBJS(Br), 1986

32. Activity Level of HTO vs UKA Gillquist, CORR, 1991

33. Manual Labor: 17/34 Jumping Sport: 45-60% Nagel, JBJS(Am), 1996 Odenbring, Acta Ortho Scan, 1989 Activity after HTO

34. HTO is better than UKA Koshino, APKS, 2006 ROM

35. HTO is better than UKA Koshino, APKS, 2006 Kneeling

36. UKA 에서 동통이 적으나, 노동은 HTO 에서 가능하다. HTO 에서 ROM 이 더 좋고, Kneeling 도 가 능 하다. Summary of Quality of Life

37. Biologic Aspect

38. Joint Space  Preop.: 1.8mm  3 Yr F-up: 2.9mm 송은규, 대한슬관절학회지, 2002 Joint Space (2Y F/U)  Koshino -Joint space ;pre-op 1.1mm post-op 2.3mm -Pattern No reg;13/146 pink and yellow fibrillation 2/143 Partial coverage 50/143 Full coverrage 16/143 13,86,47/146 Cartilage Healing after HTO

39. Pre-op Medial joint space narrowing Post-op 14 M Restored medial joint space

40. Pre-op Post-op Cartilage defect in tibia Healed cartilage Cartilage defect in femur Regenerated cartilage

41. POD 17 Months Healed cartilage defect site initial POD 17 M microfracturepost-op 2 Yr

42. Complications

43. early perioperative complication after HTO vs UKA Broughton, JBJS(Br), 1986

44. Early Cx after HTO Infection Patella baja Intraarticular fracture Peroneal nerve dysfunction Compartment syndrome Vascular injury

45. Incidence : 41% Tuner, JBJS(Br), 1993 DVT Case after HTO

46. Retained Cement after UKA Engh, J Arthroplasty, 2006

47. Easy in UKA Faster Recovery Gillquist, CORR, 1991 Rehabilitation

48. UKA 가 HTO 에비해 Rehabilitation 이 쉽 고,, Peri- operative Complication 면에 서 월등하다. Summary of early perioperative course

49. Cosmesis

50. HTO : Overcorrection UKA : Undercorrection Alignment

51. Subcondylar Osteotomy with Blade Plate Tibia Vara with Mild OA Preop.POD#5Y

52. Tibio-Femoral Angle : 13° Defective Cosmesis Unbalance compared to Contralateral Side

53. UKA : One Stage HTO : Two Stage Staged Operation in Bilateral Case

54. UKA : Immediate HTO : Delay 2-3 M Weight Bearing

55. UKA 가 HTO 에비해 Weight Bearing, Cosmesis, 면에서 월등하다. Summary of Short Term Results

56. Long tern complication

57. Long term Cx after HTO Loss of correction Arthritis opposite compartment Decreased function over time. pseudoarthrosis

58. Collapse after UKA Engh, J Arthroplasty, 2006

59. Wear after UKA Vince, J Arthroplasty, 2004

60. Dislocation after UKA

61. Fracture after UKA Vince, J Arthroplasty, 2004

62. Technical Problems & Results of Revision

63. Difficult Exposure Bone Defect Difficult Ligament Balance Prolonged Operative Time Increased Blood Loss Offset Stem Sometimes But, No Problem after Open Wedge HTO (Kitson) Injury 2001;32 Technical Problems of TKA after HTO (ICL 2004)

64. UKA : Bone Defect HTO : Difficult Exposure Gillquist, CORR, 1991 Frequent Encountered Problems at Revision

65. Less Successful (windsor 1988 JBJS) (Cameroon1996 orthopedic (Katz 1987 JBJS) More infection (Jackson J arthroplasty 1994) difficult exposure, mild decreased flexion but No difference (Haddad 2000 J arthroplasty) (Windsor) Results of TKA after HTO compared with primary TKA

66. HTO 는 Approach 시 조심해야 하며, UKA 는 Bone Defect 에 대비해야 한다. 결과는 HTO 가 UKA 후 Revision 보다 좋 다. Summary of Problems at Revision

67. We may rightfully expect Higher Failure Rates, perhaps Greater Damage in the Younger, More Active Patient. New, expanded Indications for UKA may lead to More Complications and perhaps More Severe Failures. Vince, J Arthroplasty, 2004 Can We expand Indication of UKA in Young Patients?

68. Summary

69. Faster Recovery Immediate Weight Bearing High Initial Success Rate Fewer Early Complications Simultaneous Bilateral Procedure Better Cosmesis Less Infection Less Blood Loss Less Function and Activity 80 세 이후의 노인에서 아주 좋은 결과를 얻을 수 있다. Callahan, CORR, 2005 Gillquist, CORR, 1991 Insall UKA

70. More Active Life Style Biologic Better Result at Revision than UKA 초기 문제가 많다.  Weight Bearing  Perioperative Complication  Staging Procedure  Morbidity Iorio, JBJS(Am), 2003 Gill, CORR, 1995 Chang HTO

71. J arthroplasty Oct’06

72. Although the unicompartmental prosthesis used in this series has not shown promising results and does not match the results of some other prosthesis, and the introduction of guide instruments for precise surgical techniques has currently improved the survival of UKAs to over 90% at 10 years. Therefore, we think that in patients over 60 years of age, unicompartmental osteoarthritis UKA offers Better Long-term Results than HTO. Stukenborg, The Knee, 2001 Future of UKA

73. It is proposed that Future Biologic Resurfacing, together with Computer- and even Robotic- Methods, as well as other advances in Biology and Technology, will combine to resurrect the performance of knee osteotomies Krackow, J Arthroplasty, 2004 Future of HTO

74. HTO 와 UKA 는 잘 선택될 때 좋은 결과를 얻을 수 있다. Indication, Cosmesis, Function, Biologic 면에서 완 전히 다른 수술이다. HTO 는 초기에 문제가 많고, UKA 는 후기에 문제가 있다. HTO 는 젊고 활동이 많은 환자에 유용하다. UKA 는 활동이 적은 여성이나, 80 대 이상에서 좋은 결과 를 얻을 수 있다. 장차 Biologic Procedure 와 결합되면 더 많은 HTO 가 시행될 것이다. Summary